Custom-made titanium devices as membranes for bone augmentation in implant treatment: Clinical application and the comparison with conventional titanium mesh.

OBJECTIVE: Development of new custom-made devices to reconstruct alveolar bone for implantation, and comparison with conventional methods were the goals of this study. MATERIALS AND METHODS: Using a computer-aided design technique, three-dimensional images were constructed. From these data, custom-made devices were produced by a selective laser melting method with pure titanium. Clinical trials also have been conducted with 26 participants who needed bone reconstruction before implantation; they were divided into 2 groups with 13 patients each. The first group uses custom-made devices; the other uses commercial titanium meshes that need to bend during operation. Some clinical aspects are evaluated after the trial. RESULTS: The custom-made devices can be produced closely by following the data precisely. Devices are fit for bone defect site. Moreover, the operation time of the custom-made group (75.4 ± 11.6 min) was significantly shorter than that of the conventional group (111.9 ± 17.8 min) (p < 0.01). Mucosal rupture occurs, without significant difference (p = 0.27), in a patient in the custom-made without severe infection (7.7%), and 3 in conventional (23.1%), respectively. The retaining screw is significantly fewer in the custom-made group than commercial mesh group (p < 0.01). CONCLUSION: These results indicate that our novel protocol could be simple and safe for providing powerful support for guided bone regeneration.

Optical impression method to measure three-dimensional position and orientation of dental implants using an optical tracker.

OBJECTIVES: The aim of this study was to devise an optical impression method that could make impressions of dental implants accurately and rapidly. MATERIALS AND METHODS: Four paper markers (4 × 3 mm, 8 × 6 mm, 16 × 12 mm, and 24 × 18 mm) and one titanium marker (8 × 6 mm) were prepared to determine the measuring accuracy of the three-dimensional optical tracker. For a proposed and conventional impression taking method, we compared the reproduction accuracies of the positions and orientations of dental implants and the times to obtain impressions. Finally, we fabricated computer-aided designing (CAD)/computer-aided manufacturing (CAM) superstructure frameworks to determine the adaptation accuracy. RESULTS: The 8 × 6-mm titanium marker was optimal among the prepared markers. Dental implants made by the proposed and conventional impression taking methods had measurement errors of 71 ± 31 µm and 32 ± 18 µm, respectively. The proposed method took a significantly shorter time to obtain an impression than did the conventional method. The connection between the CAD/CAM superstructure frameworks and four implant analogs had uplifts of 55 ± 10 µm, 94 ± 35 µm, 2 ± 1 µm, and 66 ± 3 µm. CONCLUSION: Our proposed method and fabricated titanium markers enabled us to measure the positions and orientations of dental implants both accurately and rapidly. We then used the reproducible measurement results for the positions and orientations of the dental implants to fabricate CAD/CAM superstructure frameworks within an acceptable accuracy range.

Development of a multi-layered virtual tooth model for the haptic dental training system.

A virtual reality (VR) haptic dental training system could be a promising tool for future dental education. One major challenge is to develop a virtual tooth model which similarly reflected a real tooth having multiple layers with different mechanical hardness in each layer. The multi-layered virtual tooth model was successfully constructed in our virtual system. The constructed model allows us to feel tooth cutting which is similar to that with a real tooth. Through a cutting experiment by using the real tooth, a spring coefficient and a damping coefficient of a dental hard tissue were determined 0.8 N/mm and 1.79 Nsec/mm respectively. The feedback force smoothly altered when crossing the border of regions having different mechanical hardnesses. The constructed model introduced in this study could be a promising tool for acquiring dental hand skills in a virtual learning system.

Metal artifacts in MRI from non-magnetic dental alloy and its FEM analysis.

Artifacts in MR(Magnetic Resonance) images of oral cavity produced from non-magnetic metal restorations was verified by measuring the image of index finger and a cylinder of fat test piece with a type 4 gold alloy ring using a compact MRI equipment. In the images of finger, portion around the ring disappeared. However, it was nearly restored with a cut ring. In the cylinder of fat test piece, obvious artifacts appeared when circumferential surface of the ring was placed perpendicular to RF(Radio Frequency) field of MRI equipment's excitation/detection coil. However, in other directions or with a cut ring, artifact disappeared. The cause was simulated with FEM(Finite Element Method) electromagnetic field analysis, and alternating magnetic field was shown to induce surface current on the continuous gold ring. Magnetic field produced by that current interfered with the field from excitation coil. This demonstrated the characteristics and cause of artifacts by non-magnetic dental metals.

Fabrication of three-dimensional cell constructs using temperature-responsive hydrogel.

A morphologically controlled three-dimensional (3D) cell construct composed of only cells and having no scaffold material might be a valuable biologic material for tissue engineering applications, as the scaffold materials can cause delay of tissue regeneration in some conditions. To obtain such a 3D cell construct, a 3D thermoresponsive hydrogel (poly-N-isopropylacrylamide) was prepared as a mold material that changes its volume depending on the temperature. Three-dimensional osteoblast cell constructs with a variety of morphologies as well as a monolayered cell sheet were obtained by decreasing the surrounding temperature of the hydrogel designed with a predefined shape and formed by curing in a polymer mold manufactured via 3D printing. The cell sheet or 3D cell constructs detachment resulted from a simple change in the gel volume, not by the surface chemistry of the gel, because the surface hydrophilicity of the gel was maintained over a wide temperature range. These 2D/3D cell constructs have numbers of exciting applications such as cell carriers for tissue regeneration or as model tissues for the biological study.

Effect of calcium ion concentrations on osteogenic differentiation and hematopoietic stem cell niche-related protein expression in osteoblasts.

Apatite biomaterials have potential not only as cell vehicles for engineering bone tissue but also as regulators of calcium (Ca) concentration in situ for controlling osteoblast functions, for example, osteogenic differentiation and fate management of hematopoietic stem cells (HSCs). To design apatite materials having optimal chemical properties for the latter purpose, more detailed investigations into what effect Ca concentrations have on osteoblast functions is crucial. In this study, osteoblasts were cultured at different Ca concentrations, and the temporal alterations in osteogenic differentiation and HSC niche-related protein (angiopoietin-1, 2 [Ang1, 2]) expression were investigated. The different Ca concentrations (1.8-50 mmol/L) in the cell culture medium had no effect on the proliferation of osteoblasts, but did on the cell morphology. The higher Ca concentrations (<6 mmol/L) enhanced the mineralization as well as Ang1 expression. In addition, Ang1 expression in osteoblasts showed higher correlation with expression of connexin43, the major marker of cell-cell interactions, whereas Ang2 related to integrin beta1, the major marker of cell-matrix interactions. Thus, the local Ca concentration regulates cell morphology through the cell-cell or cell-matrix interactions, leading to the alteration of Ang1 expression in osteoblasts. Since these changes triggered by Ca are concerned with the osteogenic differentiation or reproduction of HSCs niche microenvironment, the results obtained in this study might be useful for designing apatite materials with optimal chemical properties.

Regulation of the protein-loading capacity of hydroxyapatite by mercaptosuccinic acid modification.

Loading and releasing protein in a controllable way is extremely important for the protein vehicles used in bone tissue engineering. To obtain a suitable carrier material for basic proteins, such as BMP or bFGF, hydroxyapatite particles containing mercaptosuccinic acid (mercaptosuccinic acid (Mer), (Mer-HAp)) were synthesized. Physicochemical evaluation of Mer-HAp suggested that Mer was contained in HAp particles: it either simply adsorbed onto HAp crystals or was trapped among the HAp crystals. A protein adsorption study using basic and acidic model proteins indicated that the synthesized Mer-HAp had selective loading properties of the basic protein. The loaded protein was gradually released from Mer-HAp in phosphate buffered saline. The protein release rate was different in each Mer-HAp synthesized with a different concentration of Mer. In addition, the protein release from Mer-HAp showed a similar profile with the Ca dissolution in different pH solutions, indicating that the Mer-HAp dissolution was concerned with the protein release from Mer-HAp. Thus, Mer-HAp is a useful candidate for the basic protein carrier because it has properties which enable the loading and releasing of protein in a controllable way.

Large-area electron beam irradiation for surface polishing of cast titanium.

Cast titanium is a known hard-to-polish material, and its final polishing step is a perpetual challenge. The best way to tackle this challenge lies in automatic and non-mechanical polishing methods. Against this background, the suitability of large-area electron beam (EB) irradiation was examined in this study. In parallel, the optimum condition for efficient surface polishing was investigated. Cast titanium specimens were prepared, whereby their surface glossiness, surface roughness, and corrosion resistance were measured before and after EB irradiation. After EB irradiation, favorable results were observed: the cast titanium surface became smooth, the glossiness increased, and corrosion resistance was enhanced. These results were attributed to the low heat conductivity of titanium. With mechanical polishing, this property results in temperature rise and burnout reaction of the titanium surface with oxygen and the abrasives. However, during EB irradiation, the low heat conductivity of titanium was an advantage in raising the surface temperature to the melting point, such that a smooth surface was yielded after solidification. Based on the results obtained, automatic polishing by EB seemed to be a suitable polishing method for metal frameworks of removable dentures, and an efficient one too by saving time and effort.

Simulation of osteotomy and support for surgery using VR haptic device.

A novel computer-assisted 3-D simulation for osteotomy and CAD/CAM fabrication of surgical splints consider the relative inter-bone interference and space after bone translation were developed. CT image of a patient for osteotomy was operated and simulation of surgery for deformation, segmentation, displacement of the bone was processed effectively by virtual reality haptic device PHANTOM. CAD of a bite splint before surgery and after bone displacement was done in the process of simulation. CAM of resin bite splints was done by precise Rapid Prototyping CAM machine. All fabricated splint were sufficiently functioned to determine the position of jaws.

Dental haptic simulator to train hand skill of student - calibration method to realize visual haptic environment.

In prior work, we have developed dental training simulator to train hand skill of student (HHDTS). In the present study, we performed calibration between haptic device coordinate system and half-mirror coordinate system for our system to realize real clinical situation. As a result, the user can overlay the CG (turbine) onto the stylus of haptic device and intract to the CG (tooth) directly.

Virtual reality simulation training for dental surgery.

In dentistry the exquisite hand skill is required for daily treatments, However, dental students have little chance to treat patients in the clinical training So, present study constructed a process simulation to train the hand skill for tooth extraction, especially impacted wisdom tooth that was an example of the difficult case by using virtual reality haptic device.

Application of haptic device to implant dentistry--accuracy verification of drilling into a pig bone.

To enable accurate implant placement and precise drilling following preoperative simulation, we developed the BoneNavi system. To realize more precise drilling when the holes are upsized, two methods of surgical guiding were attempted in the present study. One involved using multiple surgical guides with titanium tubes of different diameters, and the other involved using a single surgical guide but employing titanium drill guide tubes with different diameters. Drilling accuracy of the two newly developed methods was examined and compared with the results of drilling into a pig bone using only the initial surgical guide. Deviations of the position and angle with the two novel methods were similar: 0.17 mm and 1 degree respectively. As for the control group whereby drilling was done using only the initial surgical guide, the deviations were 0.25 mm and 3.50 degrees--which were significantly larger than those achieved with the two novel methods. In light of the results obtained, our newly developed BoneNavi system is especially applicable for severe clinical cases that require precise implant placement.

Fabrication of freeform bone-filling calcium phosphate ceramics by gypsum 3D printing method.

Transformation of gypsum model fabricated by three-dimensional printing (3DP) into hydroxyapatite (HA) by treating in ammonium phosphate solution is possible. However, 3DP powder supplied by the manufacturer contains unknown additives which may be questionable for biomaterials. Accordingly, pure plaster of Paris (POP) powder was used for fabrication in the present study. For accurate fabrication, reduction of supplied binder ink to 80% of standard amount for 3DP powder supplied by the manufacturer was found to be the optimal condition for POP fabrication. Transformation from POP to HA was done by immersing into 1 mol/L ammonium phosphate solution. However, preheating of fabricated POP specimen at 200 degrees C for 30 min to change from calcium sulfate dihydrate into calcium sulfate hemihydrate could accelerate the transformation into HA effectively. To increase compressive strength, HA transformed specimen was sintering at 1150 degrees C for 3 h. The compressive strength increased four times comparing with as transformed HA specimen. However, crystal structure was transformed to beta-TCP due to the chemical reaction between the transformed HA and remained phosphate from ammonium phosphate solution at the sintering temperature. A sophisticated application of the present 3DP method to fabricate the freeform bioceramic for osseous defect was attempted, and jaw bone defect filling biomaterial of beta-TCP and scaffold with macroporous structures could be fabricated. Present 3DP method has possibility to fabricate freeform bioceramic for osseous defect or scaffold.

CAD/CAM fabrication and clinical application of surgical template and bone model in oral implant surgery.

OBJECTIVES: A novel implant surgery support system with computer simulation for implant insertion and fabrication of a surgical template that helps in drilling bone was developed. A virtual reality haptic device that gives the sense of touch was used for simulation and a surgical template was fabricated by CAD/CAM method. Surgical guides were applied for two clinical cases. MATERIAL AND METHODS: Three-dimensional (3D) jaw bone images transferred from DICOM data filmed by CT scanner were fed to the software and manipulated using the haptic device. The site for implant insertion was determined after evaluating the quality of bone and position of the mandibular canal. The surgical template was designed with ease using the free design CAD function of haptic device. The surgical template and bone model were fabricated by a fused deposit modeling machine. Two clinical cases were applied using the present system. RESULTS: Simulation to determine the site of implant insertion and fabrication of the surgical bone templates were successfully done in two clinical cases, one for three implant insertion in lower right jaw and the other is for seven implant insertion in lower edentulous jaw, respectively. During surgery, the templates could be firmly adapted on the bone and drilling was successfully performed in both cases. CONCLUSION: The present simulation and drilling support using the surgical template may help to perform safe and accurate implant surgery.

Biomimetic fabrication of fibrin/apatite composite material.

Bidirectional diffusion of the Ca and PO4 solutions into the fibrin gel was performed at various pH conditions and fluoride concentrations to generate organic/inorganic composite materials mimicking biomineralization. The minerals produced in this system had a higher crystallinity than those generated by the solution mineralization system. The minerals generated in fibrin gel varied depending on the pH conditions as follows: Dicalcium phosphate dihydrate (DCPD) in the noncontrolled pH solution, the DCPD and octacalcium phosphate (OCP) mixture at pH 7.4, and the OCP and hydroxyapatite (HAp) mixture at pH 9.0. When fluoride ions were added in the range of 2-500 ppm, the minerals produced at pH 7.4 altered from OCP/HAp to HAp/fluorapatite (FAp). In addition, the crystallinity of the obtained minerals increased with an increase in fluoride ion concentration, and the solubility was inversely correlated to crystallinity. In conclusion, we established a novel fabrication method for synthesizing organic/inorganic composite materials composed of fibrin and calcium phosphate and revealed that the characteristics of the minerals in the synthesized material can be controlled by the fabrication condition.

Three-dimensional cell and tissue patterning in a strained fibrin gel system.

Techniques developed for the in vitro reproduction of three-dimensional (3D) biomimetic tissue will be valuable for investigating changes in cell function in tissues and for fabricating cell/matrix composites for applications in tissue engineering techniques. In this study, we show that the simple application of a continuous strain to a fibrin gel facilitates the development of fibril alignment and bundle-like structures in the fibrin gel in the direction of the applied strain. Myoblasts cultured in this gel also exhibited well-aligned cell patterning in a direction parallel to the direction of the strain. Interestingly, the direction of cell proliferation was identical to that of cell alignment. Finally, the oriented cells formed linear groups that were aligned parallel to the direction of the strain and replicated the native skeletal muscle cell patterning. In addition, vein endothelial cells formed a linear, aligned vessel-like structure in this system. Thus, the system enables the in vitro reproduction of 3D aligned cell sets replicating biological tissue patterns.

Transformation of 3DP gypsum model to HA by treating in ammonium phosphate solution.

Three-dimensional printing (3DP) is a CAD/CAM built-up using ink-jet printing technique. Commercially available 3DP system can form only gypsum model and not for bioceramics. On the other hand, transformation of hardened gypsum into hydroxyapatite (HA) by treatment in ammonium phosphate solution was found lately. In the present study, transformation of the 3DP gypsum block to HA was attempted. However, the fabricated 3DP block was soluble in water. To insolubilize, it was heated at 300 degrees C for 10 min, and then, gypsum was transformed to calcium sulfate hemihydrate, CaSO(4) x 0.5H(2)O. The 3D block was immersed in 1M (NH(4))(3)PO(4) x 3H(2)O solution at 80 degrees C for 1-24 h, and the transformation into HA within 4 h was ascertained. A heat-treated plaster of Paris (POP) block was also investigated for comparison. The unheated POP block consisting of gypsum dihydrate took 24 h to complete the transformation, while the heat-treated POP consisting calcium sulfate hemihydrate promoted the transformation into HA; but the transformed thickness in the block was less than the 3DP block. This is probably due to higher solubility of the hemihydrate than gypsum dihydrate. Accelerated transformation of the 3DP block was also caused by its porous structure, which enabled an easy penetration of the phosphate solution. With the present method, it is possible to transform the fabricated gypsum by 3D printing that is adaptive to the osseous defect into HA prostheses or scaffold.

Application of virtual reality force feedback haptic device for oral implant surgery.

A novel support system for implant surgery was tried out, which involves manipulating a three-dimensional (3-D) computed tomography (CT) image of a jawbone with a virtual reality force feedback haptic device. Through this virtual system, the haptic experience of bone drilling with vibration and the sound of the contra-angle handpiece could be realized. It is expected to be useful for training inexperienced dentists and educating dental students. The simulation of oral implant insertion was also focused on. A simple cylindrical implant model was inserted into a 3-D image of the jawbone by operating the haptic device, with consideration of bone condition. A rectangular solid object that served as a bone-supported surgical template was adopted, and the shapes of the bone and the implant were subtracted from the object. In this manner, the CAD of the surgical template with impressions of the bone and the implant guide holes for insertion was realized. The surgical template was milled with a computer-controlled milling machine (CAM). Surgical template accuracy was examined with an edentulous gypsum bone model having six holes for implant insertion. Simulation of the oral implant insertion and CAD/CAM of the surgical template were conducted. The milled surgical template was fitted on the gypsum bone model, and CT images were taken. Cross-sections of the guide holes in the surgical template were imaged, and misalignment between the guide holes of the surgical template and the drilled holes on the jawbone was measured. The average misalignment is less than 0.2 mm, and it indicates that the present system is potentially applicable to oral implant surgery.

New evaluation method by microfocus radiograph CT for 3D assessment of internal adaptation of all-ceramic crowns.

The aim of this study was to evaluate the effectiveness of the microfocus radiograph CT system in examining the adaptation of all-ceramic crowns three-dimensionally and non-destructively. The computed tomograms of the crown and abutment model were filmed by microfocus radiograph CT. Using a volumetric rendering software, images of gaps were extracted and reconstructed three-dimensionally, and their volume data analyzed. In order to compare this method with the conventional method, fitness test silicone paste was sandwiched between the abutment and all-ceramic crown. Adaptation of the crown on the abutment model was then observed non-destructively and three-dimensionally. Furthermore, the gaps could be analyzed in any arbitrary position. Concerning mean gap thickness, there was significant differences between the two measurement methods. However, it was very slight. We therefore concluded that the microfocus radiograph CT system is well positioned to be an extremely effective method in examining the adaptation of all-ceramic crowns.

A novel method of removing artifacts because of metallic dental restorations in 3-D CT images of jaw bone.

CT images, especially in a three-dimensional (3-D) mode, give valuable information for oral implant surgery. However, image quality is often severely compromised by artifacts originating from metallic dental restorations, and an effective solution for artifacts is being sought. This study attempts to substitute the damaged areas of the jaw bone images with dental cast model images obtained by CT. The position of the dental cast images was registered to that of the jaw bone images using a devised interface that is composed of an occlusal bite made of self-curing acrylic resin and a marker plate made of gypsum. The patient adapted this interface, and CT images of the stomatognathic system were filmed. On the other hand, this interface was placed between the upper and lower cast models and filmed by CT together with the cast models. The position of the marker plate imaged with the dental casts was registered to those adapted by the patient. The error of registration was examined to be 0.25 mm, which was satisfactory for clinical application. The damaged region in the cranial bone images as an obstacle for implant surgery was removed and substituted with the trimmed images of the dental cast. In the method developed here, the images around the metallic compounds severely damaged by artifacts were successfully reconstructed, and the stomatognathic system images became clear, and this is useful for implant surgery.